Gout Treatment Options: Medications, Diet & Prevention (2026)

Understanding the Two Phases of Gout Treatment

Gout treatment is not one-size-fits-all. It involves two distinct phases, and confusing them is one of the most common mistakes in gout management.

Phase 1 — Acute treatment: Stops the pain and inflammation of an active gout attack. These medications are taken only during flares and for short periods.

Phase 2 — Preventive (prophylactic) therapy: Lowers uric acid levels over months and years to dissolve existing crystals and prevent new ones from forming. These medications are taken daily, long-term.

Starting preventive therapy during an active flare can temporarily worsen symptoms — this is why timing matters and why your doctor will usually wait until the flare resolves before beginning uric acid-lowering drugs.

Acute Gout Attack Medications

Colchicine

Colchicine is derived from the autumn crocus plant and has been used for gout for over 2,000 years. It works by blocking the inflammatory response to uric acid crystals.

When to use it: Most effective within the first 12-24 hours of an attack. Effectiveness drops significantly after 36 hours.

Standard dosing (AGREE trial protocol):

• 1.2 mg at the first sign of a flare
• 0.6 mg one hour later
• Then 0.6 mg once or twice daily until the flare resolves

The AGREE trial published in Arthritis & Rheumatology showed this low-dose regimen was equally effective as high-dose colchicine but with 75% fewer gastrointestinal side effects (nausea, diarrhea, vomiting).

Side effects: Diarrhea (most common), nausea, abdominal cramping. Low-dose regimens minimize these.

Caution: Dose adjustment needed for kidney disease. Dangerous interactions with certain antibiotics (clarithromycin) and statins.

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

NSAIDs are effective first-line treatment for acute gout, especially when started early.

NSAID	Typical Dose	Duration
Indomethacin	50 mg three times daily	5-7 days
Naproxen	500 mg twice daily	5-7 days
Ibuprofen	800 mg three times daily	5-7 days

Important for older adults: NSAIDs carry significant risks for people over 65, including stomach ulcers, kidney injury, and increased cardiovascular risk. The American College of Rheumatology recommends caution with NSAIDs in this age group, especially for those taking blood thinners or with existing kidney disease.

For more on NSAID risks and alternatives, see our guide on NSAID risks for chronic joint pain.

Corticosteroids

Corticosteroids are the preferred option when colchicine and NSAIDs are not suitable — which is common among Medicare-age patients with multiple health conditions.

Oral prednisone: 30-40 mg daily for 3-5 days, then tapered over 7-10 days. A randomized trial in The Lancet showed prednisone was as effective as indomethacin for acute gout with fewer side effects.

Joint injection: A corticosteroid injection directly into the affected joint provides rapid, targeted relief. Particularly useful for knee gout where a large effusion (fluid buildup) is present — the doctor can drain the fluid and inject the steroid in the same procedure.

Intramuscular injection: A single triamcinolone injection (60 mg) provides systemic relief and is convenient for patients who cannot take oral medications.

Combination Therapy for Severe Attacks

For severe flares involving multiple joints or flares not responding to single-agent therapy, the American College of Rheumatology 2020 guidelines conditionally recommend combining treatments:

• Colchicine + corticosteroids
• Colchicine + NSAIDs
• Joint aspiration + corticosteroid injection + oral colchicine

Long-Term Uric Acid-Lowering Therapy

Who Needs It?

The American College of Rheumatology recommends starting uric acid-lowering therapy if you have:

• 2 or more gout attacks per year
• Tophi (visible uric acid deposits under the skin)
• Uric acid kidney stones
• Chronic kidney disease with elevated uric acid
• Even a first flare if uric acid is above 9 mg/dL or if you have kidney disease

The goal is to lower serum uric acid below 6.0 mg/dL (below 5.0 mg/dL if tophi are present). At these levels, existing crystals slowly dissolve over 6-24 months.

Allopurinol (First-Line)

Allopurinol is the most widely prescribed uric acid-lowering drug worldwide and the first choice recommended by all major guidelines.

How it works: Blocks xanthine oxidase, the enzyme that converts purines to uric acid.

Dosing: Start low (100 mg daily, or 50 mg if you have kidney disease) and increase by 100 mg every 2-4 weeks until the uric acid target is reached. Most patients achieve their target at 200-300 mg daily, though doses up to 800 mg are approved.

Effectiveness: Reduces uric acid by 30-40% at typical doses. A 2019 meta-analysis found that 70% of patients reach their uric acid target with adequate allopurinol dosing.

Important side effect: Rare but serious hypersensitivity reaction (allopurinol hypersensitivity syndrome) occurs in less than 1% of patients. The risk is higher in patients of Korean, Thai, or African American descent. A genetic test (HLA-B*5801) before starting therapy can identify those at risk and is recommended by the ACR.

Cost: Generic allopurinol is inexpensive — typically under $10/month with Medicare.

Febuxostat (Uloric)

How it works: Also blocks xanthine oxidase, but through a different mechanism than allopurinol.

When used: For patients who cannot tolerate allopurinol or do not reach their target at maximum allopurinol doses.

Effectiveness: Slightly more potent than allopurinol — 80 mg of febuxostat lowers uric acid more than 300 mg of allopurinol in head-to-head trials.

Safety concern: The CARES trial in the New England Journal of Medicine (2018) found a slightly higher rate of cardiovascular death with febuxostat vs. allopurinol (cardiovascular death 4.3% vs. 3.2%). As a result, the FDA added a boxed warning, and febuxostat is now recommended only as a second-line agent.

Probenecid

How it works: Increases uric acid excretion through the kidneys (uricosuric agent).

When used: For patients who cannot take xanthine oxidase inhibitors, or as add-on therapy when allopurinol alone is insufficient.

Limitations: Not effective if kidney function is significantly impaired (GFR below 50). Requires drinking at least 2 liters of water daily to prevent kidney stones. Can interact with many medications.

Pegloticase (Krystexxa) — For Severe, Refractory Gout

Pegloticase is a biologic medication given as an intravenous infusion every 2 weeks. It works by converting uric acid into a harmless compound (allantoin) that is easily excreted.

When used: Reserved for patients with severe gout who have failed or cannot tolerate oral uric acid-lowering drugs — typically patients with large tophi or frequent, debilitating attacks.

Effectiveness: Dramatically lowers uric acid. In clinical trials, 42% of patients achieved the uric acid target, and many experienced resolution of tophi.

Recent advance (2022): Combining pegloticase with immunosuppression (methotrexate) increased response rates to 71% by preventing the anti-drug antibodies that cause many patients to lose response. This combination was FDA-approved and has significantly improved outcomes.

Cost: Approximately $40,000-$50,000 per year. Medicare Part B typically covers it when medical necessity criteria are met.

Flare Prevention During Treatment Initiation

When you first start uric acid-lowering therapy, shifting crystal deposits can paradoxically trigger flares. This is a major reason patients stop treatment prematurely, thinking the medication “isn’t working.”

To prevent this, doctors prescribe prophylactic colchicine (0.6 mg once or twice daily) or low-dose NSAIDs for the first 3-6 months of uric acid-lowering therapy. A clinical trial showed that this approach reduced prophylaxis-period flares by 64%.

Key message: Do not stop your uric acid-lowering medication during a flare. Treat the flare separately and continue the preventive drug.

Lifestyle Changes That Support Treatment

Medication is the foundation of gout management, but lifestyle changes enhance its effectiveness.

Diet

A gout-friendly diet can lower uric acid by 1-2 mg/dL. Key principles:

• Limit red meat, organ meats, and shellfish
• Avoid beer; limit liquor
• Eat cherries, low-fat dairy, and plenty of vegetables
• Stay well hydrated (8-12 glasses of water daily)

Weight Management

Every 5 kg (11 pounds) of weight loss reduces uric acid by approximately 1 mg/dL. Aim for gradual loss — crash diets trigger flares.

Exercise

Regular low-impact exercise improves joint health and supports weight management. During flare-free periods, consider walking, swimming, or cycling.

Newer and Emerging Treatments

IL-1 Inhibitors (Anakinra, Canakinumab)

These biologic drugs target interleukin-1, a key inflammatory molecule in gout attacks. They are used for acute flares when colchicine, NSAIDs, and corticosteroids are all contraindicated or ineffective. Anakinra (off-label, 100 mg subcutaneous injection daily for 3 days) is increasingly used in hospital settings. Canakinumab is FDA-approved for gout but costly.

Lesinurad + Allopurinol

Lesinurad is a URAT1 inhibitor that blocks uric acid reabsorption in the kidneys. Combined with allopurinol, it helps patients who do not reach their uric acid target with allopurinol alone. Available as a combination tablet (Duzallo).

Investigational Therapies

Several promising approaches are in clinical trials as of 2026:

• Tigulixostat — A novel xanthine oxidase inhibitor with potentially better tolerability
• AR882 — A potent URAT1 inhibitor in Phase 3 trials showing strong uric acid lowering
• SEL-212 — A modified uricase (like pegloticase) engineered to reduce immunogenicity

Frequently Asked Questions

How long does gout treatment take to work?

Acute medications (colchicine, NSAIDs, steroids) provide relief within hours to days. Long-term uric acid-lowering therapy takes 3-6 months to reach target levels and 12-24 months to fully dissolve crystal deposits. The first 6 months may actually bring more flares, which is why prophylactic colchicine is prescribed during this period.

Can I stop taking allopurinol once my uric acid is normal?

No. Gout is a chronic condition. Stopping uric acid-lowering medication allows uric acid to rise again and crystals to reform. Most patients need lifelong therapy. The good news: allopurinol is safe for long-term use, inexpensive, and taken once daily.

Is gout treatment different for Medicare patients?

The medications are the same, but treatment choices often differ because older patients have more kidney disease, cardiovascular conditions, and medication interactions. Corticosteroids and colchicine (at adjusted doses) are often preferred over NSAIDs, which carry higher risks in the 65+ population. Medicare Part D covers most gout medications, and Part B covers pegloticase infusions.

Do I need to see a rheumatologist for gout?

A primary care doctor can manage straightforward gout effectively. Consider seeing a rheumatologist if: you have frequent flares despite treatment, your uric acid will not reach target, you have tophi, you have kidney disease complicating treatment, or the diagnosis is uncertain. A referral is particularly valuable if your knee gout overlaps with other conditions like osteoarthritis.

Are there natural remedies that actually work for gout?

Tart cherries (35% flare reduction in clinical trials), adequate hydration, vitamin C (500 mg daily), and coffee all have evidence supporting modest benefits. However, none replace medication for patients with recurrent gout. See our complete gout diet guide for evidence-based dietary recommendations.

Can gout be cured?

Gout cannot be cured, but it can be excellently controlled. With consistent uric acid-lowering therapy that keeps levels below 6.0 mg/dL, crystals dissolve, flares stop, and tophi shrink. Many patients on effective long-term treatment become completely flare-free. The condition is manageable for life with the right approach.

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The information in this article is for educational purposes only and is not intended as medical advice. Always consult with your healthcare provider before starting or changing gout medications.

Last medically reviewed: April 2026